Healthcare Provider Details

I. General information

NPI: 1639156888
Provider Name (Legal Business Name): GRAND UNION HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 E MONROE
JAY OK
74346
US

IV. Provider business mailing address

PO BOX 409
JAY OK
74346-0409
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-4500
  • Fax: 918-253-6064
Mailing address:
  • Phone: 918-253-4500
  • Fax: 918-253-6064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberNH2104-2104
License Number StateOK

VIII. Authorized Official

Name: MRS. ORRISE MATHESON
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-253-4500